Biggest ever hip fracture audit shows improvements in care, but significant geographical variations

A report from the world’s largest and fastest-growing national hip fracture audit, published today (Thursday 2nd September) reveals that NHS hip fracture patients – often some of the most elderly and vulnerable patients in the NHS – are now getting far greater access to specialist care by geriatricians, as well as osteoporosis screening, assessment for the likelihood of future falls and bone protection drugs – which alone can reduce fracture incidence by up to 50%, potentially saving £millions to the NHS. However, the report also flags up significant variations in care quality provision between hospitals, with some patients not being assessed by appropriate doctors, having unacceptable delays before surgery, and missing out on osteoporosis care and falls prevention.

The National Hip Fracture Database National Report 2010 covers more than 36,000 hip fracture patients treated in hospitals in England, Wales, Northern Ireland and the Channel Islands. The findings include:

• 68% of patients assessed for, and 57% discharged on bone protection medicine. A further 7% awaiting a bone scan or bone clinic appointment: total 75% (up 15% from 2009). In 2007 the total figure was less than 15%.
• 60 per cent of patients now receive an assessment to determine the likelihood of future falls, with 3% awaiting appointment: total 63% (up 19% from 2009).
• 31% assessed pre-operatively by a geriatrician with 32% having other forms of medical assessment: total 63% (up 22% from 2009).
• 80 per cent of patients receive surgery within 48 hours – (up 5% from 2009.)
• 57% of patients are admitted to an orthopaedic ward within 4 hours.

However, not all hospitals are meeting best practice as set out by orthopaedic experts, and delays – which cause pain and distress, and slow up recovery – are common and must be addressed. As recently as 2007, surgeons expressed concern that this group of mostly elderly patients were not considered priority cases. However, since the introduction of the database and guidelines, 80% of hip fracture patients are now receiving surgery within the recommendation of 48 hours and more than half of patients (57%) are admitted to orthopaedic wards within the 4 hour timeframe set out by experts. Although this is a start, clinicians and managers want every single patient to receive the best possible treatment. Prompt surgery followed by good medical care and rehabilitation promotes early recovery and reduces hospital stay, all of which drive down NHS costs.

The National Hip Fracture Database is a collaboration between the British Orthopaedic Association and the British Geriatrics Society, and is funded by HQIP. Its 2010 Report identifies the hospitals participating, and also provides case studies on how clinicians and managers in individual hospitals have worked together and used the NHFD to improve the care they provide:

• The Royal Surrey Hospital introduced joint orthogeriatrician and surgical care, with the implementation of additional trauma lists, daily orthogeriatrician ward rounds, an integrated care pathway and a patient care handbook. Length of stay was reduced by 6 days, and mortality by 3%. £220,000 implementation costs were offset by £450,000 savings in bed days.
• In South Tees, a multidisciplinary project reduced delay in A&E, raised the percentage of patients having surgery within 48 hrs from 62 per cent to 81 per cent, and lowered average length of acute hospital stay from 18 days to 12.6
• In Mayday University Hospital, in Croydon, a trauma group sought to improve the hip fracture care pathway, and reduced average time to surgery from 58.8 hours to 28.9, with 87 per cent of patients waiting less than 48 hours, and average acute stay falling from 32.6 days to 22.
• In Basildon, improved medical care following the introduction of daily orthogeriatrician ward rounds resulted in a sustained fall in mortality, which had been high. The percentage of patients dying within 30 days of fracture is now only 4.9% compared with the national average of 7.7%

Rob Wakeman, NHFD’s Lead Clinician in Orthopaedic Surgery and a Consultant Orthopaedic Surgeon in Basildon, said: “Hip fractures are threatening to overwhelm trauma and orthopaedic units, and it is the responsibility of clinicians and managers to work together to come up with solutions to improve patient care in their hospital. We are seeing lots of evidence from around the UK that big improvements in the quality of hip fracture care can be achieved in a short space of time. It is vital that those few units that are still under-performing use this guidance and the examples of best practice to improve services in line with the rest of the UK.”

Hip fracture is the most common serious injury of older people. Around 76,000 hip fractures occur in the UK each year, and cost the NHS £1.4 Bn. Numbers may double by 2050. For many patients, a hip fracture brings loss of mobility or of independence at home, and mortality is high.

To further promote quality of care, the Department of Health has brought in a new Best Practice Tariff for hip fracture care. This offers financial incentives to hospitals meeting defined quality standards – including early surgery, ortho-geriatrician involvement in medical care and rehabilitation, and secondary prevention – and makes use of NHFD data to measure how these standards are being met.

Notes to editors:

1. The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its aim is to promote quality improvement, and in particular to increase the impact that clinical audit has on healthcare quality in England and Wales. HQIP hosts the contract to manage and develop the National Clinical Audit and Patient Outcomes Programme (NCAPOP). Their purpose is to engage clinicians across England and Wales in systematic evaluation of their clinical practice against standards and to support and encourage improvement in the quality of treatment and care. The programme comprises 30 clinical audits that cover care provided to people with a wide range of medical, surgical and mental health conditions, including diabetes.
2. The Fragility Fracture BOA Blue Book can be found at http://www.boa.ac.uk/en/publications/fragilty fratures/
3. The Royal College of Surgeons of England is committed to enabling surgeons to achieve and maintain the highest standards of surgical practice and patient care. Registered charity number: 212808.
4. If you have any queries please contact:

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